DEPARTMENT OF HEALTH SERVICES Division of Public Health F-05282 (Rev. 11/2016)

STATE OF WISCONSIN Wis. Stat. § 69.21

Page 1 of 2

WISCONSIN DIVORCE CERTIFICATE APPLICATION (for Mail or In-Person Requests)

PENALTIES: Any person who illegally possesses any vital record with knowledge that the vital record has been illegally obtained is guilty of a Class I felony [a fine of not more

than $10,000 or imprisonment of not more than 3 years and 6 months, or both, per Wis. Stat. § 69.24(1)].

I.

AP

PL

ICA

NT

IN

FO

RM

AT

ION

CURRENT NAME - First Last MAIL TO NAME - First (if different) Last

YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No. MAIL TO ADDRESS (if different than street address) Apt. No.

City State ZIP Code City State ZIP Code

DAYTIME TELEPHONE NUMBER

( )

EMAIL ADDRESS

TYPE OF CURRENT VALID PHOTO ID (See item 3 on page 2.)

PHOTO ID NUMBER STATE OF ISSUANCE EXPIRATION DATE

II.

AP

PL

ICA

NT

’S R

EL

AT

ION

SH

IP T

O

PE

RS

ON

(S)

NA

ME

D O

N T

HE

CE

RT

IFIC

AT

E Per Wis. Stat. § 69.20(1), a CERTIFIED copy of a divorce certificate is only available to those with a “direct and tangible interest." (A–E)

CHECK ONE box which indicates YOUR RELATIONSHIP to one of the PERSONS NAMED on the divorce certificate.

A. I am one of the persons named on the divorce certificate.

B. I am a member of the immediate family of one of the persons named on the divorce certificate.

Parent Child Brother / Sister

Maternal Grandparent Paternal Grandparent

C. I am the legal custodian or guardian of one of the persons named on the divorce certificate.

D. I am a representative authorized by any person in categories A - C, including an attorney.

Specify the person you represent: _________________________________________________________________________________

E. I can demonstrate the divorce certificate is necessary for the determination or protection of a personal or property right.

Specify your interest ___________________________________________________________________________________________

F. None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity or legal purposes.)

NOTE: Grandchildren, stepparents, stepchildren, stepbrothers / stepsisters may only obtain certified copies as categories C – E.

PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:

III.

F

EE

S

First Copy Fee ……………………………………………………………….………..…………………..……………... $ 20.00 ___20.00___

Additional copies of the same certificate issued at the same time as the first copy ___________________ X $ 3.00 ___________ Number of Additional Copies

TOTAL ___________

Submit your application materials and fee to:

Be sure to include: completed form, acceptable identification, payment, any additional proof or authorization required

IV.

DIV

OR

CE

INF

OR

MA

TIO

N

PARTY “A” BIRTH NAME - First Middle BIRTH Last Name

PARTY “B” BIRTH NAME - First Middle BIRTH Last Name

LOCATION OF DIVORCE - County COUNTYDATE OF DIVORCE (MM/DD/YYYY)

I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies of

the requested divorce certificate in accordance with the categories listed above.

SIGNATURE (Applicant)

Date Signed (MM/DD/YYYY)

Important: Signature and payment are required for processing.

TYPE or PRINT.

WISCONSIN DIVORCE CERTIFICATE APPLICATION F-05282 (Rev. 11/2016)

Page 2 of 2

1. What is the difference between a “certified” and an “uncertified” copy of a divorce certificate?

A CERTIFIED COPY:

Is printed on security paper, has a raised seal, and shows the signature of the State Registrar or Local Registrar.

Can be used for legal purposes.

Can only be obtained with a direct and tangible interest as defined in Wis. Stat. § 69.20(1).

AN UNCERTIFIED COPY:

Is printed on plain paper and marked “uncertified.”

Is for information purposes only and cannot be used for identity or legal purposes.

Contains the same information as a certified copy.

2. How long will it take to process my request?

APPLYING IN PERSON

APPLYING BY MAIL

3. What identification is required when applying for a divorce certificate?

Requests for certified copies require proof of identification. Applicant’s original ID is required for in-person applications. A photocopy of the applicant’s ID is required for mail applications.

At least one form of ID must show your name and address. Expired cards or documents will not be accepted.

Examples of acceptable forms of identification include:

One of these: OR Two of these:

State issued driver’s license or ID card

US or Foreign passport

Tribal or Military ID card

Bank/Earnings statement

Current, dated, signed lease

Health insurance card

US Government issued photo ID

Utility bill or traffic ticket

Vehicle registration/title

If you have questions regarding this form, please call

or visit our website at